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Fulminant Colitis
New Challenges
M62 Coloproctology course 2004
Issues
• Changing patterns of disease
• Developments in drug therapy
• Timing surgical intervention
• Surgical practice
Patterns of Disease IBD
• Rising incidence of Crohn’s disease
Copenhagen
– presentation
– investigation
Patterns of Disease IBD
• Rising incidence of Crohn’s disease
Copenhagen
– presentation
– investigation
Patterns of Disease
UC Crohn’s
Patterns of Disease non-IBD
• Clostridum difficile
• Vascular disease
• Immune-compromised
Pseudomembranous colitis
• Rising incidence 30-100%/10yrs• Recurrent attacks – 20%• Subtotal colectomy – 100% mortality
– Pre-op D – 46% Koss 2004
Dallal 2002
Morris 2002
Sharma 2003
Koss 2004
Source Nr Cases Cdiff
Severe Mort
Hosp 2300 64 60%
Hosp 157 51 20%
NOF 239 17 35%
Gastro 13 38%
Pseudomembranous colitis
• Immunosupression– Lung TT
• CT diagnosis
Cardiac Patients
• Major GI complications- high mortality• Surgical decisions - complex
– Cardiac surgery: scope: stool cultures
Centre Nrs GI Compl
C-
diff
Isc-aemia
Mort
Texas 11,000 147 18 17 22%
Frankf. 1,000 23 85%
Imuno-compromised patients
• Cytomegalovirus infection– Refractory colitis– 30% (16/47) infected– 8/12 responded to treatment Wada 2003
• Immunosuppressed IBD– 23/23 colitis– 0/10 CRC– 21/23 early a’gen +ve Rahbar 2003
• Mimics PMC Olfinlade 2001
Study of CMV/PMC in acute colitis required
Medical Managementdevelopments
• The Oxford criteria– the five day rule Truelove @ Jewell 1974
• Azathioprine– maintenance of remission
• Cyclosporin– induction of remission McCormack G 2002
VanAssche G 2003
Medical Managementchallenges
• Uncertain end points
• Masked sepsis
• Late relapse– immunosuppression
Mallant-Hent 2003
Surgical Issue
• UC - fragile colon
• Crohn’s - loss of planes
• Rectal stump(ed)
Surgical Issue
• UC - fragile colon
• Crohn’s - loss of planes
• Rectal stump(ed)
Surgical Developments
• One stage reconstruction– cyclosporin Hyde GM 2001
• Laparoscopy Hurley BW 2002
Marcello PW 2001
- interval procedure
• Reconstruction in Crohn’s disease?
New Challenges?
• Team management Truelove @ Jewell 1974
– MDM– Shared care– Mixed wards
Patterns of Disease non-IBD
• Broad spectrum antibiotics– pseudomembranous colitis
• Multisystem disease– ischaemic colitis
• Immune-compromised– viral infections– multifactorial disease
Clostridium Difficile
• 2,000 cases over 10 years
• 64 colectomies
• incidence rising– 0.6 - 1.2%
• life threatening cases also doubled – 3%
Dallal RM,Ann Surg. 2002